Abstinence versus contraception as pregnancy prevention methods

Abstinence vs. Contraception

Over the last thirty years, a vociferous debate has arisen over the relative merits of abstinence-only education vs. contraception, with public policy and debate often falling far short of the reality. On the one side are politicians and religious groups arguing that abstinence is the only sure way to prevent unwanted pregnancies and the transmission of sexually transmitted diseases, and as such should represent the core focus of any sexual awareness campaign. On the other side of the debate are those researchers arguing that abstinence is not only unpractical, but ineffective, and that the only proven way to reduce unwanted pregnancies and the transmission of sexually transmitted diseases is through educating the public about the proper use of contraceptives, and especially condoms. In order to get to the bottom of this debate and shed light on an issue intentionally clouded by one side, this study examined the arguments in support of abstinence-only sex education and one oft-cited example of a supposedly successful implementation of an abstinence program in Uganda before discussing a number of studies comparing the relative effectiveness of abstinence vs. contraception over the last three decades. After considering the arguments in favor of abstinence as a practical sexual education focus and comparing the effectiveness of abstinence and contraception programs, it became clear that contraception is the only effective option, and furthermore, that abstinence-only programs actually increase the likelihood of unwanted pregnancies and STD transmission, because while participants are just as likely as other groups to engage in sexual activity, they are much less likely to use contraception or protection from STDs due to their enforced ignorance of such methods.

The question of relative effectiveness is not an abstract consideration; to the contrary, the deployment of sexual education programs which stress abstinence have increased over the last thirty years while evidence for their effectiveness has failed to materialize over this same period. In 2001, Gold and Nash ("State-level policies on sexuality, STD education") found that "in examining the evolution of federal, state and local policy together, it is clear that abstinence promotion has truly taken hold as a matter of education policy in the United States and is being reflected in classroom education," having begun "on a small scale in 1981 with the enactment of the Adolescent Family Life Act" before being expanded by Congress and state legislatures. The two largest expansions of abstinence-only legislation following the AFLA were "a major freestanding program of abstinence-only education grants to the states, enacted as part of welfare reform in 1996; and a separate abstinence-only set-aside for community organizations (including those that are faith-based) within the maternal and child health (MCH) block grant" adopted in 2000. Consider the results from a 1999 study that does not even include the programs and initiatives begun under the second Bush administration:

Among the 69% of public school districts that have a district-wide policy to teach sexuality education, 14% have a comprehensive policy that treats abstinence as one option for adolescents in a broader sexuality education program; 51% teach abstinence as the preferred option for adolescents, but also permit discussion of contraception as an effective means of protecting against unintended pregnancy and disease (an abstinence-plus policy); and 35% (or 23% of all U.S. school districts) teach abstinence as the only option outside of marriage, with discussion of contraception either prohibited entirely or permitted only to emphasize its shortcomings (an abstinence-only policy). (Landry, Kaeser, & Richards, 1999, p. 280).

Thus, an overwhelming majority of school districts focused on abstinence-plus or abstinence-only sexual education, even though the efficacy of such programs had not been proven by any kind of reasonable metric.

That these impositions of abstinence-only legislation occurred at the same time as the political ascendancy of the religious right in America (first with Ronald Reagan's reign as president and then a decade later with George W. Bush) is no coincidence, because abstinence-only education is undeniably rooted in Christian conceptions of human sexuality. As Gresle-Favier (2004, p. xiii-xv) notes, "contemporary debates over abstinence education are representative of [a] 'clash' between a conservative and religious view of society and a more liberal and secular one," with the former favoring a restrictive approach to sexuality that considers anything other than heterosexual intercourse in the context of a marriage as morally deficient, while the latter simply assumes that "as long as sexual acts are consensual and responsible, they are considered legitimate." This should not be interpreted simply as an "attack" on religion, but rather as a means of understanding the fundamentally different goals of either side in this debate and the implications those goals have on either side's preferred focus.

From the more liberal and secular perspective, sexual activity or inactivity are regarded as equally worthwhile, with the only concern being the safety and health of those who do choose to engage in sexual activity. Thus, the subsequent support for contraception and contraception education arises out of evidence suggesting that these methods are most effective for ensuring the safety and health of those engaging in sexual activity (evidence that is considered in more detail later on in this study). From the conservative and religious perspective, any sexual activity outside of a heterosexual marriage is considered morally deficient and socially unacceptable, so the goal of sexual education should be to preclude this sexual activity rather than ensure the health and safety of those engaging in it. Thus, supporters of abstinence-only education need no evidence to justify their support, because abstinence is the goal in and of itself, rather than the means of achieving a larger social goal. In short, abstinence-only education is about morality, whereas contraception is about health, and the two have wildly different objectives, something that becomes clear when considering the arguments in favor of abstinence-education more closely.

Collins, Alagiri, and Summers (2002) discuss the "many different groups across the United States advocating for abstinence-only sex education in the schools," finding that the majority of them advocate the same positions and claims:

These and other proponents of abstinence-only education argue primarily that sex before marriage is inappropriate or immoral and that abstinence is the only method which is 100% effective in preventing pregnancy and STIs. Many such groups emphasize that condoms are not fool-proof in preventing pregnancy or STIs, and that sexual activity outside marriage can result in "serious, debilitating, and sometimes, deadly consequences." In addition, many abstinence only advocates are deeply concerned that information about sex, contraception and HIV can encourage early sexual activity among young people. These advocates credit the decrease in teenage pregnancy largely to the advancement of the abstinence-only message. (p. 12).

This decrease is undeniable; "from 1991 to 2001, the teenage birth rate declined significantly across the country," and "during that same decade, 1991-2001, vital statistics data show the percentage of U.S. high school students who ever had sexual intercourse and the percentage who had multiple sex partners also decreased" (Perrin & Bernecki DeJoy, 2003, p. 445). However, "the United States continues to have the highest teen pregnancy rate of all industrialized nations," and attributing this decline to abstinence programs assumes much more than the data warrants. In fact, even if this decline could be attributed to abstinence education, it still would not be very good evidence in support of the theory, because the United States' "teen pregnancy rate has declined less steeply than in other developed countries during the last thirty years," the majority of which "promote a 'Planned Parenthood' type of sexual education" (Perrin & Bernecki DeJoy, 2003, p. 445, & Gresle-Favier, 2004, p. ix). Because abstinence advocates are so committed and so impervious to reason or evidence, it is necessary to break down each of the major claims one by one in order to show how completely abstinence has failed as a public policy.

In making the case for abstinence, the claim "that abstinence is the only method which is 100% effective in preventing pregnancy and STIs" is most often trotted out first, because at first glance it appears the most unassailable position (Collins, Alagiri, & Summers, 2002, p. 12). It is of course true that the only way to ensure that one never becomes pregnant or contracts an STD/STI is to abstain from sex completely, but the idea that this fact can serve as the basis for a public policy is ludicrous, because it completely disregards the most basic realities of human behavior, especially when it comes to estimating and mitigating risk. Furthermore, that this fact is ever used as justification for abstinence-only education represents a gap in the argument, because it makes the leap from "abstinence is the only foolproof way to avoid pregnancies and STDs" to "abstinence should be the only (or at least most prominent) method of avoiding pregnancy and STDs taught to adolescents," without taking into account the reality of human sexual behavior. It pretends to hold public policy up to a nearly impossible standard, in that any mitigation effort must be 100% successful in order to be worthy of funding or implementation.

Finally, this argument confuses the effectiveness of a certain behavior (or restriction of a behavior) with the effectiveness of programs advocating that behavior. Put another way, abstinence advocates hope that saying "abstinence is the only method which is 100% effective in preventing pregnancy and STIs" will be misinterpreted by the public and politicians to mean the same thing as "abstinence-only education is the only method which is 100% effective in preventing pregnancy and STIs." This is akin to pretending that the fact that never using silverware is the only method which is 100% effective in preventing one from stabbing oneself with a fork is a reasonable justification for never using silverware, as if there were no way to still use a fork such that the risk of stabbing oneself is almost negligible. Ultimately, as Santelli et al. (2006, p. 76) note, this kind of argumentation "is misleading and potentially harmful because it con-ates theoretical effectiveness with the actual practice of abstinence," leaving those in abstinence-only programs woefully unprepared to deal with the reality of sexual experience.

The subsequent arguments in favor of abstinence education stem either from this central conceit or are more blatantly moralizing. Arguing that condoms can sometimes break or fail is just another version of the absurd 100% success-rate standard, and encouraging early sexual activity among young people (something which has not actually been shown to result from contraceptive and comprehensive sex education) is only a negative if one assumes from the outset that teenage or premarital sex is automatically something that should be discouraged.

Thus, the most common arguments in favor of abstinence have been shown to be fallacious or otherwise disingenuous even before considering the actual data regarding abstinence programs. However, just because the arguments in favor of abstinence are not valid, this does not necessarily mean that abstinence programs do not work; perhaps abstinence advocates, though ill-equipped to construct reasonable arguments nonetheless have managed to create programs that reduce sexual activity, unwanted pregnancies, and the transmission of STDs despite their otherwise glaring failures of reason and logical thought. Of course, this is not the case, and abstinence programs have not only been shown to be far less effective than contraceptive and comprehensive sexual education, but have also been seen to actually increase the likelihood of pregnancy or STDs. Before considering this abundance of evidence in more detail, however, it was useful to discuss one of the programs most commonly cited as a success by abstinence advocates, namely, Uganda's efforts to forestall the spread of HIV / AIDS during the 1980s and 1990s.

It is necessary to discuss the particular case of Uganda, not only because it is a popular example for abstinence advocates in general, but because it has actually been cited by members of Congress as justification for abstinence-only education in America. In 2003, during a debate regarding the so-called Pitts amendment to House Resolution 1298, which would have required at least 33% of a $15 billion-a-year effort to combat AIDS be spent on abstinence-only efforts, then-Majority Leader Tom Delay argued that "abstinence-based prevention programs work," and that "after years of trial and error and research, the facts, and the striking success of Uganda's abstinence program, are very clear. No other method has produced the success rates or saved as many lives as Uganda's ABC approach" (Delay 2003). Delay's comments were characteristic of the Pitts amendment's supporters, and as his role as Majority Leader demonstrates, he was advocating what was essentially the majority view of Congress at the time. However, ABC refers to "Abstain, Be faithful, use Condoms," a reasonably comprehensive approach that has been subsequently mischaracterized by abstinence advocates to mean something far more restrictive. Examining the success of Uganda's program in more detail will reveal far more nuanced and comprehensive reasons for the country's success.

Even though "between the late 1980s and mid-1990s, at a time when HIV / AIDS was well on its way toward ravaging Sub-Saharan Africa, Uganda achieved an extraordinary feat: It stopped the spread of HIV / AIDS in its tracks and saw the nation's rate of infection plummet," the idea that this success can be tied solely to abstinence is ludicrous (Cohen, 2003). The success of Uganda's program encouraged "U.S.-based social conservatives in and out of government" in their belief in the efficacy of abstinence so that "for them, ABC has become little more than an excuse and justification to promote their long-standing agenda regarding people's sexual behavior and the kind of sex education they should receive: A for unmarried people, bolstered by advocacy of B, but for most people, 'anything but C'" (Cohen, 2003). However, the reality of Uganda's program does anything but justify abstinence-only programs, and in fact, demonstrates the need to comprehensively educate people about healthy sexual practices. In fact, one study which found increased sexual abstinence in Uganda discovered that the increased abstinence was not the result of abstinence-only instruction, but rather from the following "key interventions:"

(1)Improved access to information and other resources for healthy sexual behaviour decision making.

(2) Improved adolescent to adolescent interaction regarding information and decision making relating to AIDS, sexuality and health.

(3) Improved quality of the existing district educational system in the implementation of the school health curriculum and in counselling / advice giving to students. (Shuey et al., 1999, p. 412).

Far from "information about sex, contraception and HIV" encouraging young people to engage in sex earlier and more frequently, the near-comprehensive nature of Uganda's program gave individuals the knowledge necessary to make better decisions regarding their sexual health. Cohen sums up the behavioral changes in each of the three categories of ABC and demonstrates how Uganda's success arose precisely from the combination of all three, rather than abstinence alone:

Between 1988 and 1995, the time period during which HIV prevalence was declining, key changes in behavior occurred.

• Fewer Ugandans were having sex at young ages. The proportion of young men who had ever had sex decreased substantially and the median age at which young women began having sex rose from 15.9 in 1988 to 16.3 in 1995. Importantly, however, among those people who were having sex, overall levels of sexual activity did not decline.

• Levels of monogamy increased. Sexually active men and women of all ages, particularly the unmarried, were less likely to have more than one sexual partner in a 12-month period in 1995 than in 1989. Other research has found that the proportion of men reporting three or more sexual partners also fell during the period.

• Condom use rose steeply among unmarried sexually active men and women. Among unmarried women who had had sex in the last four weeks, the proportion who used condoms at last intercourse rose from 1% in 1989 to 14% in 1995; among unmarried men, condom use rose from 2% to 22%. (Cohen, 2003).

Thus, "contrary to the assertions of social conservatives [like Tom Delay] that the case of Uganda proves that an undiluted 'abstinence-only' message is what makes the difference, there is no evidence that abstinence-only educational programs were even a significant factor in Uganda between 1988 and 1995" (Cohen, 2003). This fact is necessary to reiterate almost to the point of annoyance because Uganda represented a key example for abstinence-only advocates, and without it, their argument falls apart. Social conservatives like Delay latched onto the example of Uganda precisely because evidence for the success of abstinence-only education could not be found elsewhere, even though the United States had begun a push towards abstinence-only education well before Uganda began its ABC approach to sexual education.

As the reader will recall, the United States began its decline towards abstinence-only education with the passage of the Adolescent Family Life Act (AFLA) in 1981, offering perhaps the best place with which to begin this study's direct comparison of the relative effectiveness of abstinence and contraception. Roosa and Christopher's (1990) study "Evaluation of an abstinence-only adolescent pregnancy prevention program" considered programs created out of the AFLA in order to determine their effectiveness nearly ten years later, finding that these programs had far smaller successes than those which "used supplementary funding from other sources to include contraceptive education and/or contraceptive referral in their programs" (Roosa & Christopher, 1990, p. 363). However, perhaps even more important than their comparison of abstinence-only and contraceptive programs (as there is ample evidence regarding the inefficacy of abstinence elsewhere) is what Roosa and Christopher uncovered about the evaluation of abstinence-only programs in the first place, a discovery which helps explain the continued acceptance of abstinence as a 'legitimate' form of sexual education even in the face of overwhelming evidence suggesting otherwise.

Roosa and Christopher found that "after almost a decade of sponsoring abstinence-only pregnancy prevention programs, very little has been heard about the impact of the [AFLA] sponsored programs," because "the basic research designs for the majority of the funded programs have been too poor to provide meaningful data" due to "the lack of adequate control groups, little relationship between measures and program goals, poor quality evaluation measures, and inappropriate data analysis plans" (p. 363). In short, the AFLA abstinence-only programs were structured in such a way that their success or failure could not even be measured, let alone compared to contraception programs.

One of the few abstinence-only programs that did include an evaluation scheme found "decreases in permissive premarital sexual attitudes," but "actual sexual behaviors were not reported" so the practical efficacy of the program remains in doubt (p. 363). Thus, not only were abstinence-only programs first initiated without any evidence for their utility, but they were (intentionally, it seems) organized in such a way as to preclude any possible criticism. This further reveals the altogether moral and religious motivations behind abstinence-only education; once again, the goal is abstinence in its own right, so its advocates seem to care very little about the programs' efficacy beyond instructing people to remain abstinent. Put another way, for abstinence-only advocates, there seems to be no point in accurately evaluating the results of a program so long as that program meets the most basic requirement of condemning premarital sex.

Roosa and Christopher's study was one of the earliest to evaluate the relative efficacy of abstinence programs, but since then ample research has been conducted such that a relatively clear picture of the respective merits of abstinence and contraception programs may be established. As mentioned before, the overwhelming majority of evidence points to contraceptive and comprehensive programs as being far more beneficial than abstinence in preventing unwanted pregnancies and the transmission of STDs, and a look at a variety of different studies will demonstrate this fact to the point of exhaustion.

A 1993 study found that "adolescent pregnancy or sexually transmitted disease (STD) reduction has not occurred, despite sexuality education and abstinence programs" because these programs unnecessarily make "the assumption that adolescent sexuality is a closed system of activity among peers" and in doing so ignore the realities of teenage sexuality, and especially the fact that many partners of sexually active teens are themselves adults, such that it is entirely unrealistic to presume that sexually active teens will be able to effectively lobby their adult partners to remain abstinent (Males, 1993, p. 429). By the end of the decade pregnancy rates had "reached their lowest points since they were first measured in the early 1970s" even though "the average exposure of sexually experienced women to intercourse has changed little" in that same period, demonstrating that abstinence could not be the reason for these dropping pregnancy rates, or at least not to the extent that abstinence advocates would like to pretend (Darroch & Singh, 1999, pp. 6, 10). Later research regarding the dropping pregnancy rates determined that "abstinence has only contributed to a small percentage of the overall decline, and none for teens aged 18-19. For those ages 15-17, abstinence was responsible for about 23% of the decline," such that "the decline in U.S. adolescent pregnancy rates appears to be following the patterns observed in other developed countries, where improved contraceptive use has been the primary determinant of declining rates" (Goldin, 2006, & Santelli et al., 2007, p. 150). To see why one may confidently state that contraception and not abstinence is responsible for this decline in pregnancy rates, one need only look at practically any comparison between the two methods of sex education.

In 2002, two different studies looked at the relative merits of abstinence-only education, with the first comparing abstinence and contraception programs and the second only looking at whether or not abstinence programs delay sexual activity. The first study, by Collins, Alagiri, and Summers (p. 8) discovered what has been repeatedly stated here; namely, that there is little to no genuine evidence for the effectiveness of abstinence programs, because "a surprisingly few number of published, peer reviewed abstinence-only studies exist that demonstrate measurable behavior change among young people." In fact, "a report commissioned by the Consortium of State Physicians Resource Councils lists six studies that the Consortium says point to positive effects of the abstinence only approach," but "only one of these studies is a peer-reviewed published journal article issued in the last ten years," and even this article "does not actually review an abstinence-only program, but is instead a report […] noting that a pledge of abstinence was the factor most associated with a delay in initiation of sexual activity among those surveyed" (p. 8). Collins et al. also mention "a study published in 2001 which found that teens who take a pledge to remain virgins until they marry are much less likely to have sexual intercourse than adolescents who did not take the pledge," but even this study "found that the pledges were effective only when taken as part of a minority, although not too small, group," because adolescents were only inclined to maintain their pledge when they felt it conveyed a certain status as a member of a select group.

A more recent study has put the final nail in the coffin of the virginity pledge lie, finding that "five years after [taking a virginity] pledge, 82% of pledgers denied having ever pledged," and "pledgers and matched nonpledgers did not differ in premarital sex, sexually transmitted diseases, and anal and oral sex variables" (Rosenbaum, 2009, p. e110). In fact, not only did the study find that "the sexual behavior of virginity pledgers does not differ from that of closely matched nonpledgers," but it also discovered that "pledgers are less likely to protect themselves from pregnancy and disease before marriage," further demonstrating the actively harmful effects of abstinence-only programs. In contrast, the Collins et al. survey found that "several specific studies have demonstrated positive outcomes from sex education curricula, including delayed initiation of sexual activity, increased condom use, and decreased number of sexual partners" (p. 9). Even introducing adolescents to emergency contraception did not reduce the use of condoms or other contraception, demonstrating that far from encouraging rampant promiscuity, the greater availability of and knowledge about contraception encourages adolescents to be more conscientious about their sex lives, such that some may choose to delay sexual activity (Gold et al., 2004, p. 87).

The second 2002 study examined ten different papers that supposedly demonstrated the effectiveness of abstinence-only programs, once again finding that "there do not currently exist any abstinence-only programs with strong evidence that they either delay sex or reduce teen pregnancy" (Kirby, 2002, p. 6). Of the ten studies analyzed by Kirby (chosen due to their inclusion in an earlier Heritage Foundation paper purporting to demonstrate the effectiveness of abstinence education), "nine of them failed to provide credible evidence […] that they delayed the initiation of sex or reduced the frequency of sex," and although the remaining study "suggests that the program, Not Me, Not Now, may have delayed the initiation of sex among youth 15 and younger, but not among those 17 and younger," it nonetheless failed to provide "strong evidence" for its efficacy (p. 3, 5).